Inspection on 04/09/07 for Real Life Options 2-4 Bethecar Road

This inspection was carried out on 4th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Real Life Options 2-4 Bethecar... 13/02/07

Real Life Options 2-4 Bethecar... 08/12/05

Real Life Options 2-4 Bethecar... 22/02/05

Real Life Options 2-4 Bethecar... 06/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOME ADULTS 18-65 Real Life Options 2-4 Bethecar Road 2-4 Bethecar Road Harrow Middlesex HA1 1SF Lead Inspector Tony Lawrence Key Unannounced Inspection 4th September 2007 09:00 Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Real Life Options 2-4 Bethecar Road Address 2-4 Bethecar Road Harrow Middlesex HA1 1SF 020 8248 5867 F/P 020 8248 5867 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.reallifeoptions.org Real Life Options Mr Michael Piekarczyk Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Some of whom also have a physical handicap. Date of last inspection 13th February 2007 Brief Description of the Service: 2-4 Bethecar Road is a registered care home providing care and accommodation for up to six people who have a learning disability. The home currently has two vacancies. The registered provider is Real Life Options. The home is located in a residential area close to central Harrow and Harrow and Wealdstone. The home consists of two semi-detached houses that have been converted into one house. There is parking for up to three cars at the front of the property. The home is close to a variety of amenities that include shops, a library, a cinema, banks, a post office and restaurants. Public transport facilities, including buses and trains, are within a few minutes walk of the home. People living in the home also have their own car. The home has six single bedrooms, shared communal areas and a large, wellmaintained enclosed garden. The manager confirmed that the weekly fee for the home is £1,678. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Tuesday 4th September 2007 from 09:0o0 – 16:00. The Inspector spent time talking with people living in the home and staff on duty. He also saw all six bedrooms and communal parts of the home. The Inspector also reviewed the care of two people in more detail by talking with them and staff working with them and checking care records kept in the home. The Manager did not return the Annual Quality Assurance Assessment (AQAA) before this inspection and this evidence was not available to be included in the report. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 6 be made available in other formats on request. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a Statement of Purpose that is specific to the service, but this needs to be updated. Staff working in the home understand the importance of providing sufficient information for new residents. EVIDENCE: Staff told the Inspector that the four people living in Bethecar Road have lived together for some time. There have been two vacancies for more than nine months and staff said they did not know what plans had been made to refer new people to the home. Staff were able to describe the home’s procedures for admitting a new resident, including the importance of a full care needs assessment and pre-admission visits to the home. The home has a Statement of Purpose that accurately summarised the services provided. This important source of information for potential new residents and commissioners had not been updated since 2003. The Manager must update the Statement of Purpose to include all the information detailed in Schedule 1 of the Care Homes Regulations 2001. The updated Statement must refer to the Commission for Social Care Inspection, not the previous regulatory authority, the National Care Standards Commission. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service involves residents in planning their care and support. Staff understand the importance of people being supported to take control of their lives. EVIDENCE: During this visit the Inspector checked the care plan files for two people living in the home. He found that the home has introduced a system of ‘person centred planning’. Each plan was written in the resident’s ‘voice’ and vividly described each person’s wishes and aspirations, as well as their care needs. The Inspector also looked at the logbooks used by staff to record each person’s daily life, to see if the care plans were being followed. Both of the care plans had been reviewed in January 2007 and staff said that the next reviews were planned for later this year. The plans covered people’s daily life in the home and day service, health and communication issues. Both plans were very good at promoting independence and maximising the ability of staff to communicate with each person. The plans also included good goals to make sure that people health care needs were met, they had a holiday of their choice and their daily living skills were maintained and developed. The logbooks did not specifically refer to goals identified in the person centred plan, but there was good evidence that people are involved in making decisions about their lives. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 10 The Inspector also saw that during this visit staff frequently gave residents opportunities to make choices about aspects of their lives. One person who did not go to the day centre was asked what he wanted to do and staff made sure that he was supported to take part in activities he chose. The Inspector also saw that each person’s care plan file included risk assessments completed by staff. The plans identified specific potential risks for each person and clear guidance for staff on how these should be managed and reduced. One person’s risk assessments were dated February 2007. The second resident’s assessments were not dated and there was no evidence that they had been reviewed at the person centred planning meeting held in January 2007. The Manager must make sure that important reports and assessments are dated and regularly reviewed. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are involved in meaningful daytime activities, enabling them to access and enjoy opportunities available in the local community. EVIDENCE: During this visit the Inspector saw three people for short periods before they left for their day service at 09:30 and when they returned home at 15:30. One person’s care plan showed that he was due to remain at home and the Inspector saw that staff supported this person to take part in activities he chose throughout the day. These included a shopping trip to buy personal toiletries, followed by lunch out. Later in the day this person was given the opportunity to go out again to do some food shopping for the home. Throughout the day, the Inspector saw that each member of staff took time to give this person choices and information about what they wanted to do and allowed them sufficient time to make an informed decision to take part. When this resident chose not to take part in various options, staff respected this. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 12 Residents’ logbooks showed that staff regularly support people to take part in appropriate, meaningful activities. Both people attend local churches regularly. The Inspector saw that both individual’s care plans included information about relatives, friends and other significant people. Both people have regular contact and visits with relatives and this was well recorded in their logbooks. Care plans considered people’s sexuality and clear guidance is provided for staff to make sure that people’s rights are respected. All four people living in the home had finished breakfast when the Inspector arrived. The person who stayed at home chose to go out for lunch. Staff asked residents about the evening meal and involved people in choosing and shopping for the meal. Residents said that they could eat their meals in any of the communal rooms and the Inspector saw that these provide attractive and comfortable areas where people could enjoy mealtimes. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive effective personal and healthcare support using a person centred approach. Individual’s plans clearly record their personal and healthcare needs and how they will be met in the home. EVIDENCE: The Inspector saw that residents’ person centred care plans included information about their personal and healthcare needs and how these would be met in the home. Residents were clearly involved in the planning of their care and their wishes and preferences were clearly recorded. Both people had a Community Nursing Assessment completed by clinicians from the multidisciplinary Learning Disability Team in Harrow. The assessments were completed in February and March 2006. As with other assessments and reports (see Standard 9), the Manager must make sure that these important assessments are reviewed regularly. Care plans included evidence of good joint work with staff from other agencies around the management of epilepsy, anxiety and challenging behaviours. The Inspector felt that guidance for staff on how people should be supported with their personal care was clear and focussed on maximising people’s independence. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 14 Following requirements made at the last key inspection in February 2007, the management of residents’ prescribed medication has improved. The home’s medication policy and procedures are kept in the medication file for staff reference. All medication was securely stored and medication administration records were well completed. Staff must make sure that they record the opening date on medicinal creams used in the home to make sure that use by dates are met correctly. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. Despite the availability of local procedures, managers and staff are not making sure that people are cared for safely. Financial management is poor and people living in the home are at risk of financial abuse. Significant incidents are poorly managed and issues are not satisfactorily resolved. EVIDENCE: The home has a complaints procedure that has been produced in a format that is accessible to some people living in the home. Following this inspection, the Inspector has serious concerns about the management of some issues affecting the safety of people living and working in the home. While staff said they are following agreed procedures for financial management, this has resulted in the misuse of residents’ personal monies. The Inspector was concerned that managers in the home and the organisation providing the service had not picked up this misuse. In particular, the personal money of all four people living in the home is used regularly to pay for meals and drinks for staff supporting them outside the home. In two recent cases, residents paid £20 for their lunch as they paid for staff that were supporting them. The Inspector also saw that all four people living in the home have spent lesser sums regularly in this way. This practice is not acceptable and must be stopped immediately. There was no attempt by managers or staff to conceal this misuse, as all transactions are receipted and recorded in individual’s financial records, but the Inspector was concerned that there has been no checking of residents’ financial records by managers in the home or the provider. Regular self-audits by managers should have identified this misuse of residents’ money and the practice could have been stopped before this inspection. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 16 The Inspector discussed this with staff on duty during this visit and felt that they were confused about the home’s policy and the appropriateness of using people’s money in this way. Managers from Real Life Options must carry out an audit of people’s finances and any money that has been misused in this way must be repaid. Real Life Options must also tell the Commission about the findings of this audit. During this visit, the Inspector also saw that there had been a recent incident when a resident repeatedly hit a member of staff on the arm. The incident was recorded according to the home’s procedures and the manager took statements from staff that witnessed the incident. The incident was not reported to the Commission or the local authority, as required by the Care Homes Regulations 2001 and the local safeguarding adults procedures. The Inspector discussed this incident with staff during our visit and there was confusion about the local procedures and the importance of reporting such incidents. The last key inspection report, written following a visit in February 2007, highlighted similar issues and made requirements that all managers and staff follow the local safeguarding procedures to make sure that people are cared for safely. This has not happened and the requirement is repeated. Managers from Real Life Options must make sure that this incident is reported to the local social services department under the safeguarding adults procedures and must make sure that the Commission is told of the outcome of the referral. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are encouraged and supported to personalise their rooms. The shared areas provide a choice of communal spaces where residents can meet visitors in private. EVIDENCE: The home is located in a residential area close to central Harrow and Harrow and Wealdstone. The home consists of two semi-detached houses that have been converted into one house. There is parking for up to three cars at the front of the property. The home is close to a variety of amenities that include shops, a library, a cinema, banks, a post office and restaurants. Public transport facilities, including buses and trains, are within a few minutes walk of the home. During this visit the Inspector saw all six bedrooms, communal areas, bathrooms and toilets in the home. He felt that the home provides good standards of private and communal accommodation. In particular, residents’ bedrooms are very individual. The four rooms that were occupied were spacious, well furnished and decorated. Two residents told the Inspector that they had chosen their own furniture and most people had a TV or music Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 18 system in their room. The two vacant bedrooms were also being decorated when the Inspector visited the home. As the home comprises two 3-bedroom house joined together, there is a variety of communal rooms that people can use to spend time alone or with visitors. There is a sufficient number of bath, toilets and a wheelchair accessible shower for residents’ use. There is a large, accessible garden with garden furniture for residents’ use. During this visit the Inspector saw that all parts of the home were clean and hygienic. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staffing structure is based around delivering outcomes for the people using the service. Staff recruited confirm that the service was clear about what was involved at all stages and was robust in the following of its procedure. EVIDENCE: When the Inspector arrived, three staff were on duty and two other staff arrived at 2:00 pm to cover the afternoon shifts. This provided a minimum of three staff during the day and the Inspector felt that this level of staffing was appropriate to meet the care needs of people living in the home. Staff said that Real Life Options provide good training opportunities, including Learning Disability Award Framework induction and foundation level training and National Vocational Qualification (NVQ) training. The Manager confirmed that 7 staff have completed their NVQ qualification training and 6 other staff are were currently working towards their NVQ. Throughout this visit the Inspector saw that staff worked well together to meet the residents’ care needs. The morning staff handed over significant issues to staff working in the afternoon and each shift had a Designated Responsible Person who made sure that all necessary tasks were completed. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 20 The Inspector checked the staff rota for August and September 2007. This showed that agency staff in the home are working excessive hours. One person worked for 27 days out of 31 in August, including 13 days without a day off. A second agency member of staff worked for 29 days out of 31 in August, including 24 days without a day off. The rota planned for September showed the same two agency members of staff were due to work for 23 and 26 days out of 30, including 9 and 18 day periods without a day off. Staff working in the home, including agency staff, were also working 15 hour days, from 07:00 – 22:00 to cover vacancies. The Inspector felt that these practices could place residents at risk, as staff could be more liable to make mistakes when they had been working for extended periods without a break. He also felt that the manager had made a serious error of professional judgement by drawing up rotas that allowed staff to work excessive hours, potentially placing residents at risk. The inappropriate use of agency staff should also have been identified by managers from Real Life Options responsible for monitoring standards of care in the home. The manager and Real Life Options must review the staff rota for September to make sure that staff are not working excessive hours and residents are cared for safely at all times. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 and 43. People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a lack of management supervision in the home and poor care practise are not being identified. Agency staff are used excessively and this places people living in the home at risk. EVIDENCE: Information in the home’s Statement of Purpose is evidence that the manager is a qualified nurse with 20 years experience of working with people with a learning disability. The manager confirmed that he has almost completed the NVQ Registered Managers Award and has been registered by the Commission as a fit person to manage a care home. Given the manager’s qualification and experience the Inspector was concerned at some of the poor management practice identified during this inspection. Important evidence to inform this report was not available as the Manager did not return the Annual Quality Assurance Assessment on time. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 22 The misuse of residents’ personal money identified in Standard 23 was not picked up and the Inspector saw no evidence that the manager checks finance records to make sure procedures are followed by staff working in the home. Despite requirements made following the last key inspection in February 2007, the manager failed to report an adult protection issue to the Commission and the local authority’s Safeguarding Adults team. During this visit the Inspector checked a number of records kept in the home, including person centred plans, finance and medication records. All records were well maintained and up to date. No health and safety issues were identified during this visit. Staff who spoke to the Inspector were not aware of regular monthly monitoring visits or reports carried out by managers from Real Life Options. The provider must make sure that visits are carried out and reports are sent to the home and the Commission. The manager must make sure that staff are aware of the monthly monitoring reports and that they are used to develop practice in the home. Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 3 34 3 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 3 X 3 3 1 Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 (1) Requirement Timescale for action 31/10/07 2. YA9 15 (2) 3. YA20 13 (2) 4. YA23 13 (6) To make sure that accurate information is available for commissioners and potential new residents, the Manager must update the home’s Statement of Purpose to include all the information detailed in Schedule 1 of the Care Homes Regulations 2001. The updated Statement must refer to the Commission for Social Care Inspection, not the previous regulatory authority, the National Care Standards Commission. To make sure that people’s care 31/10/07 is provided appropriately, the Manager must make sure that important reports and assessments, including risk assessments, are dated and regularly reviewed. To make sure that people’s 31/10/07 healthcare needs are met safely, staff must record the opening date on medicinal creams used in the home to make sure that use by dates are met correctly. The practice of using residents’ 31/10/07 money to pay for staff meals is not acceptable and must be DS0000017518.V347228.R01.S.doc Version 5.2 Real Life Options 2-4 Bethecar Road Page 25 5. YA23 18(1) 6. YA23 18 (1) 7. YA23 18(1) 8. YA37 18 9. YA43 26 stopped immediately. To make sure that residents have not been financially abused, managers from Real Life Options must audit each resident’s accounts and repay any money that has been used in this way. The Commission must be told of the outcome of the provider’s financial audit. The Registered Persons must ensure that all staff receive POVA training and understand how to follow the POVA guidelines for reporting allegations of abuse. Repeat Requirement. Original timescale of 15/04/07 not met. Managers from Real Life Options must make sure that a recent incident is reported to the local social services department under the safeguarding adults procedures and must make sure that we are told of the outcome of the referral. The Registered Person must ensure that the Registered Manager checks staff understanding of adult protection reporting procedures. Repeat Requirement. Original timescale of 15/04/07 not met. The manager and Real Life Options must review the staff rota for September to make sure that staff are not working excessive hours and residents are cared for safely at all times. The provider must make sure that monthly monitoring visits are carried out and reports are sent to the home and the Commission. The manager must make sure that staff are aware of the monthly monitoring DS0000017518.V347228.R01.S.doc 31/10/07 31/10/07 31/10/07 31/10/07 31/10/07 Real Life Options 2-4 Bethecar Road Version 5.2 Page 26 reports and that they are used to develop practice in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Real Life Options 2-4 Bethecar Road DS0000017518.V347228.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!